Mortality pattern in Emergency Department of a Tertiary Care Center in Western Nepal

Background : There is abundance of evidence regarding various aspects of mortality in emergency department from different parts of world but there is limited number of studies on mortality in context of western Nepal. The objectives of this analysis were to review the demographical pattern of mortalities and define the cause and frequency of death in the Emergency Department (ED) of our institute within 24 hours of treatment process.Material and Methods : A retrospective study was carried out evaluating all patients who died during the treatment process in the Emergency Department of Lumbini Medical College in a three and half year of period from January 2014 to June 2017.Results : A total of 33,472 patients attended to ED with mortality rate of 36.4%, 33.6% and 28.2% on consecutive three years in which 110 deaths occurred. There were 66 (60%) male and 44 (40%) female. The highest mortality was seen after age of 60 years (range 2 month to 90 year). Non-communicable causes &amp; stroke deaths were found to be higher in number. Most of our patient n=52 (47.3%) death occurred within 6-12 hours of admission in ED.Conclusion : Mortality within 24 hours of presentation at ED remains high. Well organized emergency setup, transport, development of protocol as well as new guideline will definitely help in reducing hospital mortalities.Journal of Nobel Medical CollegeVolume 6, Number 2, Issue 11 (July-December, 2017) Page:48-52</jats:p

A Rare Case of Leptomeningeal Carcinomatosis Secondary to Metastatic Non-Small Cell Lung Carcinoma.

Leptomeningeal carcinomatosis is a rare complication of metastatic systemic malignancy, with lung cancer being the most common cause. We present a case of a 75-year-old man with a past medical history of right non-small cell lung carcinoma and ischemic stroke who presented with a persistent headache and swallowing difficulties. On evaluation, the patient was initially diagnosed with a subacute infarct of the right posterior frontal lobe following magnetic resonance imaging (MRI). The patient\u27s headache and dysphagia worsened, increasing the possibility of brain metastasis. The patient underwent cerebrospinal fluid analysis including cytology and multiple MRI studies with no obvious explanation for the symptoms. The patient eventually developed multiple cranial nerve palsies, and a diagnosis of leptomeningeal carcinomatosis was made with neuroradiology consultation for the MRI

Symptomatic Meckel\u27s Diverticulum Presenting As Recurrent Gastrointestinal Bleeding in an Adult.

A 51-year-old male presented to the hospital with recurrent gastrointestinal bleeding. Prior work up with an esophagogastroduodenoscopy (EGD), colonoscopy, and video capsule endoscopy failed to reveal a bleeding source. Given a history of a terminal ileum diverticulum noted on previous colonoscopy and persistence of hematochezia, a Meckel\u27s scan was performed, which revealed abnormal uptake suspicious for a Meckel\u27s diverticulum containing ectopic gastric mucosa. After surgical resection, pathology confirmed a Meckel\u27s diverticulum with gastric heterotopia. This case highlights the importance of considering Meckel\u27s diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. Moreover, it is important to note that a Meckel\u27s diverticulum can be missed on video capsule endoscopy

Immune Checkpoint Inhibitor-Induced Lymphocytic Esophagitis.

Immune checkpoint inhibitors (ICIs) have emerged as effective treatments for a wide variety of advanced malignancies. However, their use is associated with numerous immune-related toxicities, including within the gastrointestinal tract. We present a rare case of checkpoint inhibitor-induced lymphocytic esophagitis. A 79-year-old male with a past medical history significant for metastatic renal clear cell carcinoma on nivolumab presented to the hospital with dysphagia and symptomatic choledocholithiasis. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for the extraction of stones and esophagogastroduodenoscopy (EGD) for dysphagia, which showed esophagitis. Biopsies revealed lymphocytic infiltration of the epithelium, dyskeratotic keratinocytes, and acanthosis, raising suspicion for nivolumab-associated lymphocytic esophagitis. Treatment includes proton pump inhibitors and steroids; however, efficacy is not well described due to the rarity of the condition

Alcoholic Hepatitis Mimicking Iron Overload Disorders With Hyperferritinemia and Severely Elevated Transferrin Saturation: A Case Report.

Iron overload disorders can present as non-specific symptoms and develop gradually but, if untreated, can be very fatal. The common causes include multiple blood transfusions for chronic anemia and increased iron absorption, including hereditary hemochromatosis (HH). HH is one of the common causes of iron overload disorders and usually presents with liver cirrhosis in a setting of significantly elevated ferritin and elevated transferrin saturation. Alcoholic hepatitis is a clinical syndrome of progressive inflammatory liver injury associated with long-term heavy intake of ethanol. However, in patients with alcohol abuse, excessive alcohol consumption can disrupt iron metabolism releasing large amounts of iron into circulation. This can cause severely elevated ferritin due to disruption of iron metabolism, simulating iron overload disorders such as HH, especially if the patient also has liver cirrhosis. Even though a high transferrin saturation of greater than 45% is recommended as a cutoff transferrin value as high sensitivity for detecting iron overload disorders, it has a low specificity and positive predictive value and often identifies people with other causes of acutely elevated ferritin levels such as alcohol liver disease and hepatitis. Recognizing this feature and timely management can spare the patient from unnecessary phlebotomies and prompt treatment for alcoholic hepatitis. We present an interesting case of severe alcoholic hepatitis mimicking HH with severely elevated ferritin levels and transferrin saturation with underlying liver cirrhosis